Horizon NJ Health Pre-Authorization Codes Managed by eviCore

Tikka Attach

Code Code Description

33214

Upgrade of implanted pacemaker system, conversion of single
chamber system to dual chamber system (includes removal of
previously placed pulse generator, testing of existing lead,
insertion of new lead, insertion of new generator)

33221
Insertion of pacemaker pulse generator only; with existing
multiple leads

33224

Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, with attachment to previously placed
pacemaker or pacing cardioverter-defibrillator pulse generator
(including revision of pocket, removal, insertion, and/or
replacement of existing generator)

33225

Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, at time of insertion of pacing cardioverter-
defibrillator or pacemaker pulse generator (including upgrade
to dual chamber system and pocket revision) (list separately in
addition to code for primary procedure)

33227
Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; single lead system

33228
Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; dual lead system

33229

Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; multiple lead
system

33230
Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing dual leads

33231
Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing multiple leads

33240
Insertion of pacing cardioverter-defibrillator pulse generator
only; with existing single lead

33249

Insertion or replacement of permanent pacing cardioverter-
defibrillator system with transvenous lead(s), single or dual
chamber

33262

Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; single lead system

33263

Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; dual lead system

Horizon NJ Medicaid and FIDE-SNP
Radiology and Cardiology Code list



Code Code Description

33264

Removal of pacing cardioverter-defibrillator pulse generator
with replacement of pacing cardioverter-defibrillator pulse
generator; multiple lead system

33270

Insertion or replacement of permanent subcutaneous
implantable defibrillator system, with subcutaneous electrode,
including defibrillation
threshold evaluation, induction of arrhythmia, evaluation of
sensing for
arrhythmia termination, and programming or reprogramming
of sensing
or therapeutic parameters, when performed

72275 Epidurography, radiological supervision and interpretation

72285
Discography, cervical or thoracic, radiological supervision and
interpretation

72295
Discography, lumbar, radiological supervision and
interpretation

74261
Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; without contrast material

74262

Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; with contrast material(s)
including non-contrast images, if performed

74263
Computed tomographic (CT) colonography, screening,
including image postprocessing

78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine

78699
Unlisted nervous system procedure, diagnostic nuclear
medicine

78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine

0042T

Cerebral perfusion analysis using computed tomography with
contrast administration, including post-processing of
parametric maps with determination of cerebral blood flow,
cerebral blood volume, and mean transit time

0501T

Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software
analysis of functional data to assess the severity of coronary
artery disease; data preparation and transmission, analysis of
fluid dynamics and simulated maximal coronary hyperemia,
generation of estimated FFR model, with anatomical data
review in comparison with estimated FFR model to reconcile
discordant data, interpretation and report



Code Code Description

0502T

Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; data preparation and transmission

0503T

Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; analysis of fluid dynamics and
simulated maximal coronary hyperemia, and generation of
estimated FFR model

0504T

Noninvasive estimated coronary fractional flow reserve (FFR)
derived from coronary computed tomography angiography
data using computation fluid dynamics physiologic simulation
software analysis of functional data to assess the severity of
coronary artery disease; anatomical data review in comparison
with estimated FFR model to reconcile discordant data,
interpretation and report

C8921
Transthoracic echocardiography with contrast for congenital
cardiac anomalies; complete

C8922
Transthoracic echocardiography with contrast for congenital
cardiac anomalies; follow-up or limited study

C8923

Transthoracic echocardiography with contrast, real-time with
image documentation (2d) with or without m-mode
recording;complete

C8924

Transthoracic echocardiography with contrast, real-time with
image documentation (2d) with or without m-mode recording;
follow-up or limited study

C8925

Transeophageal echocardiography (tee) with contrast, real
time with image documentation (2d) (with or without m-mode
recording); including probe placement, image acquistion,
interpretation and report

C8926

Transeophageal echocardiography (tee) with contrast for
congenital cardiac anomalies; including probe placement,
image acquistion, interpretation and report

C8928

Transthoracic echocardiography with contrast, real-time with
image documentation (2d), with or without m-mode recording,
during rest and cariovascular stress test using treadmill, bicycle
exercise and/or pharmacologically induced stress, with
interpretati



Code Code Description

C8929

Transthoracic echocardiography, with contrast, or without
contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when
performed, complete, with spectral doppler echocardiography,
and with color flow doppler

C8930

Transthoracic echocardiography, with contrast, or without
contrast followed by with contrast, real-time with image
documentation (2d), includes m-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise

G0297 Low dose cancer screening

70336
Magnetic resonance (eg, proton) imaging, temporomandibular
joint(s)

70450
Computed tomography, head or brain; without contrast
material

70460
Computed tomography, head or brain; with contrast
material(s)

70470
Computed tomography, head or brain; without contrast
material, followed by contrast material(s) and further sections

70480
Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; without contrast material

70481
Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; with contrast material(s)

70482

Computed tomography, orbit, sella, or posterior fossa or outer,
middle, or inner ear; without contrast material, followed by
contrast material(s) and further sections

70486
Computed tomography, maxillofacial area; without contrast
material

70487
Computed tomography, maxillofacial area; with contrast
material(s)

70488
Computed tomography, maxillofacial area; without contrast
material, followed by contrast material(s) and further sections

70490
Computed tomography, soft tissue neck; without contrast
material

70491
Computed tomography, soft tissue neck; with contrast
material(s)

70492
Computed tomography, soft tissue neck; without contrast
material followed by contrast material(s) and further sections

70496

Computed tomographic angiography, head, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing



Code Code Description

70498

Computed tomographic angiography, neck, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing

70540
Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s)

70542
Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; with contrast material(s)

70543

Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s), followed by contrast
material(s) and further sequences

70544
Magnetic resonance angiography, head; without contrast
material(s)

70545
Magnetic resonance angiography, head; with contrast
material(s)

70546

Magnetic resonance angiography, head; without contrast
material(s), followed by contrast material(s) and further
sequences

70547
Magnetic resonance angiography, neck; without contrast
material(s)

70548
Magnetic resonance angiography, neck; with contrast
material(s)

70549

Magnetic resonance angiography, neck; without contrast
material(s), followed by contrast material(s) and further
sequences

70551
Magnetic resonance (eg, proton) imaging, brain (including
brain stem); without contrast material

70552
Magnetic resonance (eg, proton) imaging, brain (including
brain stem); with contrast material(s)

70553

Magnetic resonance (eg, proton) imaging, brain (including
brain stem); without contrast material, followed by contrast
material(s) and further sequences

70554

Magnetic resonance imaging, brain, functional MRI; including
test selection and administration of repetitive body part
movement and/or visual stimulation, not requiring physician or
psychologist administration

70555

Magnetic resonance imaging, brain, functional MRI; requiring
physician or psychologist administration of entire
neurofunctional testing

71250 Computed tomography, thorax; without contrast material
71260 Computed tomography, thorax; with contrast material(s)

71270
Computed tomography, thorax; without contrast material,
followed by contrast material(s) and further sections

71275

Computed tomographic angiography, chest (noncoronary),
with contrast material(s), including noncontrast images, if
performed, and image postprocessing



Code Code Description

71550

Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s)

71551

Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); with
contrast material(s)

71552

Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy); without
contrast material(s), followed by contrast material(s) and
further sequences

71555
Magnetic resonance angiography, chest (excluding
myocardium), with or without contrast material(s)

72125
Computed tomography, cervical spine; without contrast
material

72126 Computed tomography, cervical spine; with contrast material

72127
Computed tomography, cervical spine; without contrast
material, followed by contrast material(s) and further sections

72128
Computed tomography, thoracic spine; without contrast
material

72129 Computed tomography, thoracic spine; with contrast material

72130
Computed tomography, thoracic spine; without contrast
material, followed by contrast material(s) and further sections

72131
Computed tomography, lumbar spine; without contrast
material

72132 Computed tomography, lumbar spine; with contrast material

72133
Computed tomography, lumbar spine; without contrast
material, followed by contrast material(s) and further sections

72141
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; without contrast material

72142
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; with contrast material(s)

72146
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, thoracic; without contrast material

72147
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, thoracic; with contrast material(s)

72148
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; without contrast material

72149
Magnetic resonance (eg, proton) imaging, spinal canal and
contents, lumbar; with contrast material(s)



Code Code Description

72156

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; cervical

72157

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; thoracic

72158

Magnetic resonance (eg, proton) imaging, spinal canal and
contents, without contrast material, followed by contrast
material(s) and further sequences; lumbar

72159
Magnetic resonance angiography, spinal canal and contents,
with or without contrast material(s)

72191

Computed tomographic angiography, pelvis, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing

72192 Computed tomography, pelvis; without contrast material
72193 Computed tomography, pelvis; with contrast material(s)

72194
Computed tomography, pelvis; without contrast material,
followed by contrast material(s) and further sections

72195
Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s)

72196
Magnetic resonance (eg, proton) imaging, pelvis; with contrast
material(s)

72197

Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s), followed by contrast material(s) and
further sequences

72198
Magnetic resonance angiography, pelvis, with or without
contrast material(s)

73200
Computed tomography, upper extremity; without contrast
material

73201
Computed tomography, upper extremity; with contrast
material(s)

73202
Computed tomography, upper extremity; without contrast
material, followed by contrast material(s) and further sections

73206

Computed tomographic angiography, upper extremity, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing

73218
Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; without contrast material(s)

73219
Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; with contrast material(s)

73220

Magnetic resonance (eg, proton) imaging, upper extremity,
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences

73221
Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; without contrast material(s)



Code Code Description

73222
Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; with contrast material(s)

73223

Magnetic resonance (eg, proton) imaging, any joint of upper
extremity; without contrast material(s), followed by contrast
material(s) and further sequences

73225
Magnetic resonance angiography, upper extremity, with or
without contrast material(s)

73700
Computed tomography, lower extremity; without contrast
material

73701
Computed tomography, lower extremity; with contrast
material(s)

73702
Computed tomography, lower extremity; without contrast
material, followed by contrast material(s) and further sections

73706

Computed tomographic angiography, lower extremity, with
contrast material(s), including noncontrast images, if
performed, and image postprocessing

73718
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s)

73719
Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; with contrast material(s)

73720

Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s), followed by
contrast material(s) and further sequences

73721
Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material

73722
Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; with contrast material(s)

73723

Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material(s), followed by contrast
material(s) and further sequences

73725
Magnetic resonance angiography, lower extremity, with or
without contrast material(s)

74150 Computed tomography, abdomen; without contrast material
74160 Computed tomography, abdomen; with contrast material(s)

74170
Computed tomography, abdomen; without contrast material,
followed by contrast material(s) and further sections

74174

Computed tomographic angiography, abdomen and pelvis,
with contrast material(s), including noncontrast images, if
performed, and image postprocessing

74175

Computed tomographic angiography, abdomen, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing



Code Code Description

74176
Computed Tomography, Abdomen And Pelvis; Without
Contrast Material

74177
Computed Tomography, Abdomen And Pelvis; With Contrast
Material(S)

74178

Computed Tomography, Abdomen And Pelvis; Without
Contrast Material In One Or Both Body Regions, Followed By
Contrast Material(S) And Further Sections In One Or Both Body
Regions

74181
Magnetic resonance (eg, proton) imaging, abdomen; without
contrast material(s)

74182
Magnetic resonance (eg, proton) imaging, abdomen; with
contrast material(s)

74183

Magnetic resonance (eg, proton) imaging, abdomen; without
contrast material(s), followed by with contrast material(s) and
further sequences

74185
Magnetic resonance angiography, abdomen, with or without
contrast material(s)

74712 MRI Fetal single/first gestation
74713 MRI Fetal each additional gestation

75557
Cardiac magnetic resonance imaging for morphology and
function without contrast material;

75559
Cardiac magnetic resonance imaging for morphology and
function without contrast material; with stress imaging

75561

Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences;

75563

Cardiac magnetic resonance imaging for morphology and
function without contrast material(s), followed by contrast
material(s) and further sequences; with stress imaging

75571

COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST
MATERIAL, WITH QUANTITIVE EVALUATION OF CORONARY
CALCIUM

75572 CARDIAC CT FOR MORPHOLOGY
75573 CARDIAC CT FOR CONGENITAL HD
75574 CORONARY CTA

75635

Computed tomographic angiography, abdominal aorta and
bilateral iliofemoral lower extremity runoff, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing

76376

3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; not requiring image
postprocessing on an independent workstation



Code Code Description

76377

3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; requiring image postprocessing
on an independent workstation

76380 Computed tomography, limited or localized follow-up study
76390 Magnetic resonance spectroscopy
76391 Magnetic resonance (eg, vibration) elastography

76497
Unlisted computed tomography procedure (eg, diagnostic,
interventional)

76498
Unlisted magnetic resonance procedure (eg, diagnostic,
interventional)

77021

Magnetic resonance imaging guidance for needle placement
(eg, for biopsy, needle aspiration, injection, or placement of
localization device) radiological supervision and interpretation

77022
Magnetic resonance imaging guidance for, and monitoring of,
parenchymal tissue ablation

77046
Magnetic resonance imaging, breast, without contrast
material; unilateral

77047
Magnetic resonance imaging, breast, without contrast
material; bilateral

77048

Magnetic resonance imaging, breast, without and with contrast
material(s),
including computer-aided detection (CAD real-time lesion
detection,
characterization and pharmacokinetic analysis), when
performed; unilateral

77049

Magnetic resonance imaging, breast, without and with contrast
material(s),
including computer-aided detection (CAD real-time lesion
detection,
characterization and pharmacokinetic analysis), when
performed; bilateral

77078
Computed tomography, bone mineral density study, 1 or more
sites; axial skeleton (eg, hips, pelvis, spine)

77084
Magnetic resonance (eg, proton) imaging, bone marrow blood
supply

78012

THYROID UPTAKE, SINGLE RO MULTIPLEQUANTITATIVE
MEASUREMENT(S) (INCLUDING
STIMULATION,SUPPRESSION,OR DISCHARGE, WHEN
PERFORMED)

78013
THYROID IMAGING, (INCLUDING VASCULAR FLOW,WHEN
PERFORMED)



Code Code Description

78014

THYROID IMAGING, (INCLUDING VASCULAR FLOW,WHEN
PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S)
QUANTITATIVE MEASUREMENT(S) (INCLUDING
STIMULATION,SUPPRESSION, OR DISCHARGE, WHEN
PERFORMED)

78015
Thyroid carcinoma metastases imaging; limited area (eg, neck
and chest only)

78016
Thyroid carcinoma metastases imaging; with additional studies
(eg, urinary recovery)

78018 Thyroid carcinoma metastases imaging; whole body

78020
Thyroid carcinoma metastases uptake (List separately in
addition to code for primary procedure)

78070 Parathyroid imaging

78071

PARATHYROID PLANAR IMAGING (INCLUDING
SEBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC
(SPECT)

78072

PARATHYROID PLANAR IMAGING (INCLUDING
SEBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC
(SPECT), AND CONCURRENTLY ACQUIRED
COMPUTEDTOMOGRPAHY (CT) FOR ANATOMICAL
LOCALIZATION.

78075 Adrenal imaging, cortex and/or medulla
78102 Bone marrow imaging; limited area
78103 Bone marrow imaging; multiple areas
78104 Bone marrow imaging; whole body
78185 Spleen imaging only, with or without vascular flow
78195 Lymphatics and lymph nodes imaging
78201 Liver imaging; static only
78202 Liver imaging; with vascular flow
78205 Liver imaging (SPECT);
78206 Liver imaging (SPECT); with vascular flow
78215 Liver and spleen imaging; static only
78216 Liver and spleen imaging; with vascular flow

78226
Hepatobiliary system imaging, including gallbladder when
present;

78227

Hepatobiliary system imaging, including gallbladder when
present; with pharmacologic intervention, including
quantitative measurement(s) when performed

78230 Salivary gland imaging;
78231 Salivary gland imaging; with serial images
78232 Salivary gland function study
78258 Esophageal motility
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264 Gastric emptying imaging study (eg, solid, liquid, or both)
78265 Gastric emptying imaging study



Code Code Description
78266 Gastric emptying imaging study
78278 Acute gastrointestinal blood loss imaging

78290
Intestine imaging (eg, ectopic gastric mucosa, Meckel's
localization, volvulus)

78291
Peritoneal-venous shunt patency test (eg, for LeVeen, Denver
shunt)

78300 Bone and/or joint imaging; limited area
78305 Bone and/or joint imaging; multiple areas
78306 Bone and/or joint imaging; whole body
78315 Bone and/or joint imaging; three phase study
78320 Bone and/or joint imaging; tomographic (SPECT)

78414

Determination of central c-v hemodynamics (non-imaging) (eg,
ejection fraction with probe technique) with or without
pharmacologic intervention or exercise, single or multiple
determinations

78428 Cardiac shunt detection

78445
Non-cardiac vascular flow imaging (ie, angiography,
venography)

78451 MPI, SPECT, SINGLE REST OR STRESS
78452 MPI, SPECT, MULTIPLE, REST OR STRESS
78453 MPI, PLANAR, SINGLE REST OR STRESS
78454 MPI, PLANAR, MULTIPLE, REST OR STRESS
78456 Acute venous thrombosis imaging, peptide
78457 Venous thrombosis imaging, venogram; unilateral
78458 Venous thrombosis imaging, venogram; bilateral

78459
Myocardial imaging, positron emission tomography (PET),
metabolic evaluation

78466
Myocardial imaging, infarct avid, planar; qualitative or
quantitative

78468
Myocardial imaging, infarct avid, planar; with ejection fraction
by first pass technique

78469
Myocardial imaging, infarct avid, planar; tomographic SPECT
with or without quantification

78472

Cardiac blood pool imaging, gated equilibrium; planar, single
study at rest or stress (exercise and/or pharmacologic), wall
motion study plus ejection fraction, with or without additional
quantitative processing

78473

Cardiac blood pool imaging, gated equilibrium; multiple
studies, wall motion study plus ejection fraction, at rest and
stress (exercise and/or pharmacologic), with or without
additional quantification

78481

Cardiac blood pool imaging, (planar), first pass technique;
single study, at rest or with stress (exercise and/or
pharmacologic), wall motion study plus ejection fraction, with
or without quantification



Code Code Description

78483

Cardiac blood pool imaging, (planar), first pass technique;
multiple studies, at rest and with stress (exercise and/ or
pharmacologic), wall motion study plus ejection fraction, with
or without quantification

78491
Myocardial imaging, positron emission tomography (PET),
perfusion; single study at rest or stress

78492
Myocardial imaging, positron emission tomography (PET),
perfusion; multiple studies at rest and/or stress

78494

Cardiac blood pool imaging, gated equilibrium, SPECT, at rest,
wall motion study plus ejection fraction, with or without
quantitative processing

78496

Cardiac blood pool imaging, gated equilibrium, single study, at
rest, with right ventricular ejection fraction by first pass
technique (List separately in addition to code for primary
procedure)

78579 Pulmonary ventilation imaging (eg, aerosol or gas)
78580 Pulmonary perfusion imaging, particulate

78582
Pulmonary ventilation (eg, aerosol or gas) and perfusion
imaging

78597
Quantitative differential pulmonary perfusion, including
imaging when performed

78598
Quantitative differential pulmonary perfusion and ventilation
(eg, aerosol or gas), including imaging when performed

78600 Brain imaging, less than 4 static views;
78601 Brain imaging, less than 4 static views; with vascular flow
78605 Brain imaging, minimum 4 static views;
78606 Brain imaging, minimum 4 static views; with vascular flow
78607 Brain imaging, tomographic (SPECT)

78608
Brain imaging, positron emission tomography (PET); metabolic
evaluation

78609
Brain imaging, positron emission tomography (PET); perfusion
evaluation

78610 Brain imaging, vascular flow only

78630
Cerebrospinal fluid flow, imaging (not including introduction of
material); cisternography

78635
Cerebrospinal fluid flow, imaging (not including introduction of
material); ventriculography

78645
Cerebrospinal fluid flow, imaging (not including introduction of
material); shunt evaluation

78647
Cerebrospinal fluid flow, imaging (not including introduction of
material); tomographic (SPECT)

78650 Cerebrospinal fluid leakage detection and localization
78660 Radiopharmaceutical dacryocystography
78700 Kidney imaging morphology;
78701 Kidney imaging morphology; with vascular flow



Code Code Description

78707
Kidney imaging morphology; with vascular flow and function,
single study without pharmacological intervention

78708

Kidney imaging morphology; with vascular flow and function,
single study, with pharmacological intervention (eg,
angiotensin converting enzyme inhibitor and/or diuretic)

78709

Kidney imaging morphology; with vascular flow and function,
multiple studies, with and without pharmacological
intervention (eg, angiotensin converting enzyme inhibitor
and/or diuretic)

78710 Kidney imaging morphology; tomographic (SPECT)
78725 Kidney function study, non-imaging radioisotopic study

78730
Urinary bladder residual study (List separately in addition to
code for primary procedure)

78740 Ureteral reflux study (radiopharmaceutical voiding cystogram)
78761 Testicular imaging with vascular flow

78800
Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); limited area

78801
Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); multiple areas

78802
Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); whole body, single day imaging

78803
Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); tomographic (SPECT)

78804

Radiopharmaceutical localization of tumor or distribution of
radiopharmaceutical agent(s); whole body, requiring two or
more days imaging

78805
Radiopharmaceutical localization of inflammatory process;
limited area

78806
Radiopharmaceutical localization of inflammatory process;
whole body

78807
Radiopharmaceutical localization of inflammatory process;
tomographic (SPECT)

78811
Positron emission tomography (PET) imaging; limited area (eg,
chest, head/neck)

78812
Positron emission tomography (PET) imaging; skull base to mid-
thigh

78813 Positron emission tomography (PET) imaging; whole body

78814

Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; limited area
(eg, chest, head/neck)



Code Code Description

78815

Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; skull base to
mid-thigh

78816

Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; whole body

93303
Transthoracic echocardiography for congenital cardiac
anomalies; complete

93304
Transthoracic echocardiography for congenital cardiac
anomalies; follow-up or limited study

93306

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, complete, with spectral Doppler echocardiography,
and with color flow Doppler echocardiography

93307

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, complete, without spectral or color Doppler
echocardiography

93308

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, follow-up or limited study

93313 Echocardiography, transesophageal, placement of probe
93314 Echocardiography, transesophageal, image acquisition
93315 Transesophageal, echocardiography
93316 Transesophageal, echocardiography, placement of probe
93317 Transesophageal, echocardiography, image acquistion

93350

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation

93351

Echocardiography, transthoracic, real-time with image
documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using
treadmill, bicycle exercise and/or pharmacologically induced
stress, with interpretation

93452

LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION, WHEN PERFORMED

93453

COMBINED RIGHT AND LEFT HEART CATHETERIZATION
INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT
VENTRICULOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION, WHEN PERFORMED



Code Code Description

93454

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION;

93455

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH CATHETER
PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY,
FREE ARTERIAL VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY

93456

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT HEART
CATHETERIZATION

93457

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH CATHETER
PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY,
FREE ARTERIAL, VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY AND RIGHT HEART CATHETERIZATION

93458

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED

93459

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S)
(INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS)
WITH BYPASS GRAFT ANGIOGRAPHY



Code Code Description

93460

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT
HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED

93461

CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING
SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT
HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S)
(INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS)
WITH BYPASS GRAFT ANGIOGRAPHY

93462

Left heart catheterization by trans septal puncture through
intact septum or by trans apical puncture (List separately in
addition to code for primary procedure)

C8900 Magnetic resonance angiography with contrast, abdomen

C8901 Magnetic resonance angiography without contrast, abdomen

C8902
Magnetic resonance angiography without contrast followed by
with contrast, abdomen

C8903 Magnetic resonance imaging with contrast, breast; unilateral

C8905
Magnetic resonance imaging without contrast followed by with
contrast, breast; unilateral

C8906 Magnetic resonance imaging with contrast, breast; bilateral

C8908
Magnetic resonance imaging without contrast followed by with
contrast, breast; bilateral

C8909
Magnetic resonance angiography with contrast, chest
(excluding myocardium)

C8910
Magnetic resonance angiography without contrast, chest
(excluding myocardium)

C8911
Magnetic resonance angiography without contrast followed by
with contrast, chest (excluding myocardium)

C8912
Magnetic resonance angiography with contrast, lower
extremity

C8913
Magnetic resonance angiography without contrast, lower
extremity

C8914
Magnetic resonance angiography without contrast followed by
with contrast, lower extremity

C8918 Magnetic resonance angiography with contrast, pelvis
C8919 Magnetic resonance angiography without contrast, pelvis



Code Code Description

C8920
Magnetic resonance angiography without contrast followed by
with contrast, pelvis

C8931
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST,
SPINAL CANAL AND CONTENTS (crosswalk to 72159)

C8932
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST,
SPINAL CANAL AND CONTENTS (crosswalk to 72159)

C8933

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND
CONTENTS (crosswalk to 72159)

C8934
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST,
UPPER EXTREMITY (crosswalk to 73225)

C8935
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST,
UPPER EXTREMITY (crosswalk to 73225)

C8936

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY (crosswalk
to 73225)

G0219
PET imaging whole body; melanoma for non-covered
indications

G0235 PET imaging, any site, not otherwise specified

G0252

PET imaging, full and partial-ring pet scanners only, for initial
diagnosis of breast cancer and/or surgical planning for breast
cancer (e.g., initial staging of axillary lymph nodes)

S8037 Magnetic resonance cholangiopancreatography (mrcp)
S8042 Magnetic resonance imaging (MRI), low-field

S8085
Fluorine-18 fluorodeoxyglucose (f-18 fdg) imaging using dual-
head coincidence detection system (non-dedicated pet scan)


Radiology and Cardiology


Code Code Description

19294

Preparation of tumor cavity, with placement of
radiation therapy applicator for intraoperative

radiation therapy (IORT), concurrent with partial
mastectomy

19296

Placement of radiotherapy afterloading
expandable catheter (single or multichannel)
into the breast for interstitial radioelement
application following partial mastectomy,

includes imaging guidance; on date separate
from partial mastectomy

19297

Placement of radiotherapy afterloading
expandable catheter (single or multichannel)
into the breast for interstitial radioelement
application following partial mastectomy,

includes imaging guidance; concurrent with
partial mastectomy (List separately in addition

to code for primary procedure)

19298

Placement of radiotherapy after loading
brachytherapy catheters (multiple tube and
button type) into the breast for interstitial

radioelement application following (at the time
of or subsequent to) partial mastectomy,

includes imaging guidance

31643

Bronchoscopy, rigid or flexible, including
fluoroscopic guidance, when performed; with

placement of catheter(s) for intracavitary
radioelement application

32553

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), percutaneous, intra-thoracic, single
or multiple

41019

Placement of needles, catheters, or other
device(s) into the head and/or neck region
(percutaneous, transoral, or transnasal) for

subsequent interstitial radioelement application

49411

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), percutaneous, intra-abdominal,
intra-pelvic (except prostate), and/or
retroperitoneum, single or multiple

Horizon NJ Medicaid and FIDE-SNP
Radiation Therapy Code List



Code Code Description

49412

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), open, intra-abdominal, intrapelvic,
and/or retroperitoneum, including image

guidance, if performed, single or multiple (List
separately in addition to code for primary

procedure)

55875

Transperineal placement of needles or catheters
into prostate for interstitial radioelement
application, with or without cystoscopy

55876

Placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers,

dosimeter), prostate (via needle, any approach),
single or multiple

55920

Placement of needles or catheters into pelvic
organs and/or genitalia (except prostate) for

subsequent interstitial radioelement application

57155
Insertion of uterine tandem and/or vaginal

ovoids for clinical brachytherapy

57156
Insertion of a vaginal radiation afterloading

apparatus for clinical brachytherapy

58346
Insertion of Heyman capsules for clinical

brachytherapy

61796

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); 1

simple cranial lesion

61797

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); each

additional cranial lesion, simple (List separately
in addition to code for primary

procedure)

61798

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); 1

complex cranial lesion

61799

Stereotactic radiosurgery (particle beam,
gamma ray, or linear accelerator); each
additional cranial lesion, complex (List

separately in addition to code for primary
procedure)

61800

Application of stereotactic headframe for
stereotactic radiosurgery (List

separately in addition to code for primary
procedure)



Code Code Description

76873

Ultrasound, transrectal; prostate volume study
for brachytherapy treatment planning (separate

procedure)

76965
Ultrasonic guidance for interstitial radioelement

application

77014
Computed tomography guidance for placement

of radiation therapy fields

77261
Therapeutic radiology treatment planning;

simple

77262
Therapeutic radiology treatment planning;

intermediate

77263
Therapeutic radiology treatment planning;

complex

77280
Therapeutic radiology simulation-aided field

setting; simple

77285
Therapeutic radiology simulation-aided field

setting; intermediate

77290
Therapeutic radiology simulation-aided field

setting; complex

77293

Respiratory motion management simulation
(List separately in addition to code for primary

procedure)

77295
3-dimensional radiotherapy plan, including dose-

volume histograms

77299
Unlisted procedure, therapeutic radiology

clinical treatment planning

77300

Basic radiation dosimetry calculation, central
axis depth dose calculation, TDF, NSD, gap

calculation, off axis factor, tissue inhomogeneity
factors, calculation of non-ionizing radiation
surface and depth dose, as required during

course of treatment, onl

77301

Intensity modulated radiotherapy plan,
including dose-volume histograms for target and
critical structure partial tolerance specifications

77306

Teletherapy isodose plan; simple (1 or 2
unmodified ports directed to a single area of

interest), includes basic dosimetry calculation(s)

77307

Teletherapy isodose plan; complex (multiple
treatment areas, tangential ports, the use of
wedges, blocking, rotational beam, or special

beam considerations), includes basic dosimetry
calculation(s)



Code Code Description

77316

Brachytherapy isodose plan; simple
(calculation[s] made from 1 to 4 sources, or

remote afterloading brachytherapy, 1 channel),
includes basic dosimetry calculation(s)

77317

Brachytherapy isodose plan; intermediate
(calculation[s] made from 5 to 10 sources, or

remote afterloading brachytherapy, 2-12
channels), includes basic dosimetry

calculation(s)

77318

Brachytherapy isodose plan; complex
(calculation[s] made from over 10 sources, or
remote afterloading brachytherapy, over 12

channels), includes basic dosimetry
calculation(s)

77321
Special teletherapy port plan, particles,

hemibody, total body

77331

Special dosimetry (eg, TLD, microdosimetry)
(specify), only when prescribed by the treating

physician

77332
Treatment devices, design and construction;

simple (simple block, simple bolus)

77333

Treatment devices, design and construction;
intermediate (multiple blocks, stents, bite

blocks, special bolus)

77334

Treatment devices, design and construction;
complex (irregular blocks, special shields,
compensators, wedges, molds or casts)

77336

Continuing medical physics consultation,
including assessment of treatment parameters,
quality assurance of dose delivery, and review

of patient treatment documentation in support
of the radiation oncologist, reported per week

of therapy

77338

Multi-leaf collimator (MLC) device(s) for
intensity modulated radiation therapy (IMRT),

design and construction per IMRT plan
77370 Special medical radiation physics consultation

77371

Radiation treatment delivery, stereotactic
radiosurgery (SRS), complete course of

treatment of cranial lesion(s) consisting of 1
session; multi-source Cobalt 60 based

77372

Radiation treatment delivery, stereotactic
radiosurgery (SRS), complete course of

treatment of cranial lesion(s) consisting of 1
session; linear accelerator based



Code Code Description

77373

Stereotactic body radiation therapy, treatment
delivery, per fraction to 1 or more lesions,

including image guidance, entire course not to
exceed 5 fractions

77385

Intensity modulated radiation treatment
delivery (IMRT), includes guidance and tracking,

when performed; simple

77386

Intensity modulated radiation treatment
delivery (IMRT), includes guidance and tracking,

when performed; complex

77387

Guidance for localization of target volume for
delivery of radiation treatment, includes
intrafraction tracking, when performed

77399

Unlisted procedure, medical radiation physics,
dosimetry and treatment devices, and special

services

77401
Radiation treatment delivery, superficial and/or

ortho voltage, per day
77402 Radiation treatment delivery, >1 MeV; simple

77407

Radiation treatment delivery; two separate
treatment areas; three or more ports on a single

treatment area; or three or more simple
blocks;>=1 MeV; intermediate

77412

Radiation treatment delivery; three or more
separate treatment areas; custom blocking;

tangential ports; wedges; rotational beam; field-
in-field or other tissue compensation that does
not meet IMRT guidelines; or electron beam;

>=1 MeV; complex
77417 Therapeutic radiology port image(s)

77423

High energy neutron radiation treatment
delivery; 1 or more isocenter(s) with coplanar or

non-coplanar geometry with blocking and/or
wedge, and/or compensator(s)

77424
Intraoperative radiation treatment delivery, x-

ray, single treatment session

77425
Intraoperative radiation treatment delivery,

electrons, single treatment session

77427 Radiation treatment management, 5 treatments

77431

Radiation therapy management with complete
course of therapy consisting of 1 or 2 fractions

only

77432

Stereotactic radiation treatment management
of cranial lesion(s) (complete course of

treatment consisting of 1 session)



Code Code Description

77435

Stereotactic body radiation therapy, treatment
management, per treatment course, to 1 or

more lesions, including image guidance, entire
course not to exceed 5 fractions

77469 Intraoperative radiation treatment management

77470

Special treatment procedure (eg, total body
irradiation, hemibody radiation, per oral or

endocavitary irradiation)

77499
Unlisted procedure, therapeutic radiology

treatment management

77520
Proton treatment delivery; simple, without

compensation

77522
Proton treatment delivery; simple, with

compensation
77523 Proton treatment delivery; intermediate
77525 Proton treatment delivery; complex

77600
Hyperthermia, externally generated; superficial

(ie, heating to a depth of 4 cm or less)

77605
Hyperthermia, externally generated; deep (ie,

heating to depths greater than 4 cm)

77610
Hyperthermia generated by interstitial probe(s);

5 or fewer interstitial applicators

77615
Hyperthermia generated by interstitial probe(s);

more than 5 interstitial applicators

77620
Hyperthermia generated by intracavitary

probe(s)

77750
Infusion or instillation of radioelement solution

(includes 3-month follow-up care)

77761
Intracavitary radiation source application;

simple

77762
Intracavitary radiation source application;

intermediate

77763
Intracavitary radiation source application;

complex

77767
HDR radionuclide skin surface brachytherapy;

lesion diameter up to 2.0 cm or 1 channel

77768

HDR radionuclide skin surface brachytherapy;
lesion diameter over 2.0 cm and 2 or more

channels, or multiple lesions

77770
HDR radionuclide interstitial or intracavitary

brachytherapy; 1 channel

77771
HDR radionuclide rate interstitial or

intracavitary brachytherapy; 2 to 12 channels



Code Code Description

77772
HDR radionuclide interstitial or intracavitary

brachytherapy; over 12 channels

77778

Interstitial radiation source application,
complex, includes supervision, handling, loading

of radiation source when performed

77789
Surface application of low dose rate

radionuclide source

77790
Supervision, handling, loading of radiation

source
77799 Unlisted procedure, clinical brachytherapy

79005
Radiopharmaceutical therapy, by oral

administration; used for I-131 treatment

79101
Radiopharmaceutical therapy, by intravenous

administration

79403

Radiopharmaceutical therapy, radiolabeled
monoclonal antibody by intravenous

infusion

0394T
HDR electronic brachytherapy, skin surface

application, per fraction

0395T
HDR electronic brachytherapy, interstitial or

intracavitary treatment, per fraction

A9606
Radium ra-223 dichloride, therapeutic, per

microcurie (Xofigo)

C2616
Brachytherapy source, nonstranded, yttrium-90,

per source

G0339

Image guided robotic linear accelerator-based
stereotactic radiosurgery, complete course of

therapy in one session or first session of
fractionated treatment

G0340

Image guided robotic linear accelerator-based
stereotactic radiosurgery, delivery including

collimator changes and custom plugging,
fractionated treatment, all lesions, per session,

second through fifth sessions, maximum 5
sessions per course of treatment

G6001
Ultrasonic guidance for placement of radiation

therapy fields

G6002

Stereoscopic x-ray guidance for localization of
target volume for the delivery of radiation

therapy

G6003

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: up to 5mev



Code Code Description

G6004

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: 6-10mev

G6005

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: 11-19mev

G6006

Radiation treatment delivery, single treatment
area,single port or parallel opposed ports,

simple blocks or no blocks: 20mev or greater

G6007

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: up to

5mev

G6008

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single

treatment area, use of multiple blocks: 6-10mev

G6009

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 11-

19mev

G6010

Radiation treatment delivery, 2 separate
treatment areas, 3 or more ports on a single

treatment area, use of multiple blocks: 20 mev
or greater

G6011

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; up to 5mev

G6012

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,

compensators, electron beam; 6-10mev

G6013

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,
compensators, electron beam; 11-19mev

G6014

Radiation treatment delivery,3 or more
separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam,

compensators, electron beam; 20mev or greater

G6015

Intensity modulated treatment delivery, single
or multiple fields/arcs,via narrow spatially and
temporally modulated beams, binary, dynamic

mlc, per treatment session



Code Code Description

G6016

Compensator-based beam modulation
treatment delivery of inverse planned treatment
using 3 or more high resolution (milled or cast)

compensator, convergent beam modulated
fields, per treatment session

G6017

Intra-fraction localization and tracking of target
or patient motion during delivery of radiation
therapy (eg, 3d positional tracking, gating, 3d
surface tracking), each fraction of treatment


Radiation Therapy